COVID-19 pandemic and the restrictive measures implemented by many governments in order to control it, have posed challenging questions in the management and care of people around the world. Compliance to not only short but also medium and long term social distancing measures can be particularly difficult for people with neurodevelopmental disorders such as Attention Deficit Hyperactivity Disorder (ADHD). Adherence to the long term social distancing measures is of particular interest nowadays that most countries discuss the relaxing of the restrictive measures and the level of individual responsibility will play a crucial role in avoiding resurgence in infections.

While the ADHD management of youngsters during the COVID-19 pandemic has already been discussed [1], it is necessary to consider the handling of adults with ADHD as well, especially in regard of medium and long term measures. The prevalence of ADHD in adults is estimated to be in the range of 2-5% [2]. Among the most impairing nuclear symptoms of ADHD that persist in adulthood are impulsivity and mood instability. In addition, adults with ADHD often present increased levels of procrastinating behavior, excessive mind wondering and low self-esteem while anxiety and depression are the most frequent co-occurring psychiatric disorders [3, 4].

The “stay at home” condition implemented by many countries, including Greece, has helped in the prevention of the spread of the pandemic. On the other hand it is often considered as a “no escape” situation that may trigger anxiety and claustrophobic type responses. When it is for a short period of time, individuals with ADHD can cope with this kind of unpleasant feelings. Adherence to requirements for social distancing for a long period, though, may be an extremely difficult situation for anxious people with low self–esteem, mood instability and impulsive behavior. Procrastination and avoidant behavior make it even harder.

Furthermore, the most effective medication for nuclear ADHD symptoms is stimulants, drugs that may increase heart rate and blood pressure and affect the onset of sleep [5]. Anxiety symptoms related to the COVID-19 crisis can be mistakenly attributed to possible adverse effects of medication. This misattribution combined with the fear that cardiovascular disease can make an individual susceptible to severe complications during a coronavirus infection, might lead eventually to discontinuation of the stimulants. Without appropriate treatment, impulsivity and mood instability persist and make compliance with long term social distancing measures more difficult.

Special attention should also be given to families when ADHD is present in more than one members of it. Poorly controlled parents with ADHD are at a great risk of failing to meet the needs of their children even more so of children with ADHD.

We suggest therefore that during COVID-19 pandemic while implementing long term social distancing measures we should detect -without stigmatizing- those populations that will have difficulty committing to less restrictive measures. Adults with ADHD are among these vulnerable groups that need specific attention and support. Telepsychiatry can then play a pivotal role in providing psychoeducation, coaching and psychotherapeutic interventions as well as drug monitoring not only during the strict measures period but also during the after the “stay at home” period. Overcoming the COVID-19 threat is a marathon race not a sprint.

References

1. Cortese S, Asherson P, Sonuga-Barke E et al. (2020) ADHD management during the COVID-19 pandemic: guidance from the European ADHD Guidelines Group. Lancet Child and Adolescent Health. [View]
2. Fayyad J, Sampson NA, Hwang I, et al. (2017) The descriptive epidemiology of DSM-IV adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord. 9: 47-65. [View]
3. Kooij SJ, Bijlenga D, Salerno L, et al. (2019) Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry. 56: 14-34. [View]
4. Pehlivanidis A, Papanikolaou K, Spyropoulou A, Papadimitriou NG (2014) Comorbid attention-deficit/hyperactivity disorder in adult psychiatric outpatients with depressive or anxiety disorders. Int J Psychiatry Clin Pract. 2014; 12:1- 7. [View]
5. Bolea-Alamanac B, Nutt DJ, Adamou M, et al. (2014) Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British Association for Psychopharmacology. J Psychopharmacol (Oxford) 28: 179–203. [View]